Middleton and Moncrieff1 make a good case for being cautious about prescribing antidepressants in primary care. The discussion is, however, somewhat one sided. The responsible GP will be aware that there is always a suicide risk if a severely depressed patient is sent away without an antidepressant. Being on the waiting list for cognitive behavioural therapy will not necessarily prevent suicide. Patients who commit suicide have a low concentration of serotonin in the brain.2 An experienced GP will also know of patients who have been symptom free on antidepressants who experience breakthrough symptoms when they try to wean themselves off the drug.
The old RCGP dictum that every diagnosis should have a physical, social, and psychological component is especially relevant to treatment of depression. The physical component must surely be serotonin deficiency in many cases but it would be wrong to treat this deficiency and ignore the psychological and social components which might be more important.
Recent evidence suggests a link between the physical component of depression and nutritional deficiencies.3–5 The evidence for omega-3 and antidepressants working synergistically is especially convincing.6 Recently, when a patient reported breakthrough depression symptoms, I doubled her selective-serotonin reuptake inhibitor dose and added an over-the-counter high dose omega-3. At follow-up, she told me: ‘I feel normal for the first time in over 3 years’. Could this be just a placebo effect?
REFERENCES
- 1.Middleton H, Moncrieff J. ‘They won't do any harm and might do some good’: time to think again on the use of antidepressants. Br J Gen Pract. 2011;61(582):47–49. doi: 10.3399/bjgp11X548983. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Anderson IM, Haddad PM. Prescribing antidepressants: time to be dimensional and inclusive. Br J Gen Pract. 2011;61(582):50–52. doi: 10.3399/bjgp11X548992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lacasse JR, Leo J. Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med. 2005;2(12):e392. doi: 10.1371/journal.pmed.0020392. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ioannidis JPA. Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials? Philos Ethics Humanit Med. 2008;3:14. doi: 10.1186/1747-5341-3-14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression. Cochrane Database Syst Rev. 2004;(1) doi: 10.1002/14651858.CD003012.pub2. CD003012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Moncrieff J, Cohen D. How do psychiatric drugs work? BMJ. 2009;338:b1963. doi: 10.1136/bmj.b1963. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Horwitz AV, Wakefield JC. The loss of sadness: how psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press; 2007. [DOI] [PubMed] [Google Scholar]
- 8.Summerfield D. Depression: epidemic or pseudo-epidemic? J R Soc Med. 2006;99(3):161–162. doi: 10.1258/jrsm.99.3.161. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Aldous P. Psychiatry's civil war. New Scientist. 2009;2738:39–41. (Dec) [Google Scholar]